‘We cannot pour from an empty cup’: Boundaries, connections can help ensure work-life balance
When it comes to work-life balance, clinicians in the past skewed more toward the former.
However, shifting demographics in the medical workforce, increasing capacity for communication and the COVID-19 pandemic fundamentally altered that calculus.
“The expectation and acceptance that physicians should work all day and all week with no time for themselves and their families has definitely changed,” Maryam Lustberg, MD, MPH, director of The Breast Center at Smilow Cancer Hospital at Yale New Haven, as well as chief of breast medical oncology at Yale Cancer Center, told Healio. “There is a definite recognition of the risk for burnout and that no job is worth the sacrifice of family and health.”
Explanations for this shift vary. One easy narrative is that older physicians are more willing to work while younger ones are not. However — as is often the case — the reality is likely more complicated.
“People in my generation are not opposed to working hard,” Lena K. Makaroun, MD, MS, assistant professor of medicine in the division of geriatric medicine at University of Pittsburgh School of Medicine, told Healio. “You do not go into medicine if you are afraid of working hard. This is not a cushy field.
“What I think is true of our generation is that we make sure to appreciate and value our lives holistically,” Makaroun added. “[This] includes work, but [it] also includes our families, hobbies and social activities.”
There likely is more at play than merely recent changes in attitude and priorities, according to Dike Drummond, MD, CEO of TheHappyMD.com.
There are important structural differences between the professional worlds in which providers from the baby boom generation cut their teeth in compared with those of their younger counterparts, Drummond said.
“Resident work hour restrictions mean that they graduate with one-third less total clinical experience and are never pushed as hard or abused as much as those who graduated in the days without work hour restrictions,” he said. “They are not as harshly programmed to overextend themselves and were trained in an environment with existing wellness programs.”
Despite this background, younger generations in some ways face more demands than their predecessors, according to Leah M. Katz, MD, MPH, assistant professor of radiation oncology at Columbia University Irving Medical Center.
“Retired physicians who were not as connected electronically do not realize how much administrative work we have to do simply to communicate with our patients,” Katz said.
Patients today have no shortage of ways to contact their physicians, even beyond calls, texts or emails, Katz added.
“There are also [electronic medical record] systems that allow for direct communication from patient to physician,” she said. “You can easily spend 2 or 3 hours a day — and sometimes 4 or 5 hours — just responding to all of this. It is a completely different ecosystem.”
This “response fatigue” exacerbates the physical fatigue of the job, Katz said. However, increased communication is not the only important recent shift.
“Medicine used to be male dominated, and ideally more women in medicine would imply a sharing of household duties, but this is not necessarily the case,” Katz said. “A large body of evidence shows that even in dual-physician households, as much as 80% of the housework and child care duties still fall on women.”
For these reasons and others, physicians are reassessing whether the traditional way of practicing medicine — combined with the current socio-organizational landscape — is still a healthy and sustainable model, according to Aline Charabaty, MD, associate professor of clinical medicine at Johns Hopkins School of Medicine and clinical director of the Inflammatory Bowel Disease Center at Johns Hopkins-Sibley Memorial Hospital.
“As physicians, we cannot pour from an empty cup,” Charabaty said. “A healthy, rewarding personal life is as important, if not more important, than our career.”
‘Constant distraction’
In a paper published in 2022 in Frontiers in Psychology, Kerksieck and colleagues described the phenomenon of increased access to physicians. This trend accelerated with each advance in communication technology and went into overdrive during the COVID-19 pandemic.
Developments in digitalization increased the “interference of the work and nonwork life domains,” according to the authors, putting pressure on many to continuously manage engagement with patients.
“Incoming communications are a constant distraction,” Katz said. “The volume is almost incomprehensible.”
Katz acknowledged today’s patients can be more engaged and informed. However, they also can command more time.
Meanwhile, shifting work habits triggered by the pandemic exacerbated the challenges.
“With everyone working from home and few options for social activities, everyone started to expect everyone else to be available all the time,” Katz said. “There are no real boundaries between working and not working.”
The expectation that technology would free providers to have more open communication with patients has devolved into something decidedly less helpful, Makaroun said.
“The promise of technology was that it would take care of the technical aspects of our jobs and allow us to communicate more with patients in the clinic,” she said. “It has not delivered on that promise. In many ways, technology has taken the personal connection out of practicing medicine.”
Another disruption exacerbated by the pandemic is shifting public sentiment, Makaroun added.
“In the immediate moment of COVID, the health care profession was seen as an essential workforce,” she said. “But in the medium- and long-term, there has been this backlash against the scientific community and public health officials. That has evolved into distrust of medical professionals. It takes a toll.”
Possibly the most critical difference between baby boomers and later generations that grew up with digital communications — at least regarding the workforce — is that younger clinicians are more likely to voice their concerns — big and small — publicly, Drummond said.
“The current generation of doctors is also much more active on social media, so you can witness their struggles and burnout in the comments on massive Facebook groups,” he said.
‘Oh, hell no’
Two of five active U.S. physicians are set to reach retirement age in the next decade, a trend that likely will exacerbate burnout.
An estimated 45% of American physicians are aged older than 55 years, according to Association of American Medical Colleges. A shortage of more than 100,000 physicians in the United States is predicted by 2030.
“This is a massive underestimate,” Drummond said. “There are disastrous demographics for our aging physician workforce. This makes it so difficult to prioritize work-life balance that we are seeing waves of doctors leaving the practice that will only worsen over time. We lost 100,000 doctors who quit practice in 2023 and we will lose at least 100,000 more in 2024.”
Many senior physicians have retired in recent years, either because they could not financially sustain increased administrative burdens, because of the pandemic or both, Charabaty said.
“Short staffing of nurses is causing ER backups of immense proportions in many cities around the country right now,” Drummond said. “Many young physicians who came through restricted residency programs are looking at these conditions and saying, ‘Oh, hell no’ and walking away.”
The impact on work-life balance is clear.
“Everywhere, you see physician services or call rotations that are missing one or two of their senior and hardest-working members at the same time they are missing two float nurses and [a medical assistant].” Drummond said. “Everyone must work themselves to exhaustion every day just to make sure the patients are seen.”
This is where the “programming” of older physicians — to solider on through the shortages — comes into play, Drummond said. However, this tendency can reinforce some negative behaviors among administrators, he said.
“When you are a good doctor and you show up when you are short staffed and see the patients no matter how hard it is to get through the day, that looks really good on the profit-and-loss statement,” Drummond said. “The CFO will look at the numbers from your department and pat the leader on the back for running a tight ship. There is a massive financial disincentive to staff appropriately and there is no place to find the staff that are needed for the reasons above.”
Katz, meanwhile, argued there is, in fact, an incentive for both health systems and providers to work toward better satisfaction among employees.
“Happy doctors produce better patient outcomes,” she said.
An ‘impossible position’
As medical societies and professional organizations grapple with retirement and replenishment issues, another demographic shift in the workforce is impacting work-life balance priorities — the increased proportion of women in medicine.
In a 2019 paper published in International Journal of Women’s Dermatology, Raffi and colleagues surveyed 127 women in dermatology about work-life balance. A significant proportion of respondents required household help in the form of nannies to perform chores.
“The professional women in our cohort may be balancing work and life at the expense of personal physical and mental health with little time to exercise and fewer hours of sleep per night,” Raffi and colleagues wrote.
This phenomenon has been observed across specialties.
In a paper published in 2021 in Open Heart, Castles and colleagues surveyed 452 health care providers about work-life balance factors in cardiology. Results showed women in cardiology worked more hours and were more likely to be on call than women in other specialties. They also were less likely to agree that they led a balanced life, or that their specialty was female- or family-friendly.
“A lot of female physicians are put in an impossible position,” Katz said. “Some of us are lucky to have full-time child care, but many who have their children in day care are constantly stressed about pick-up times and excess costs. Many women do not have options, which inhibits their ability to advance in their careers.”
Although some hospitals and health systems offer day care or are generally more understanding about these challenges, this type of assistance is still not the norm.
“Women have been particularly dissatisfied with the current medical model and affected by burnout,” Charabaty said. “There is an excessive burden placed on them to both excel in their medical career while still being responsible for most of the domestic and parenting activities. Delayed plans to start a family, and the lack of fair and comprehensive parental leave policies, add barriers toward a satisfying work and life integration.”
‘Freedom and flexibility’
All of these issues can culminate, ultimately, in physicians feeling powerless in their positions.
“There is a lack of control over the way physicians can practice medicine,” Makaroun said, citing increased administrative burdens, more documentation and seemingly constant oversight from nonmedical personnel. “There is little freedom and flexibility to use our training and intuition to manage patients how we see fit.”
This creates the sense that medicine is a job rather than a calling, she added.
“We went into health care ... because of some drive or passion to help people,” Makaroun said. “When our autonomy is removed and we are treated like employees, it makes sense that we are less willing to sacrifice ourselves because we are not allowed to practice in a way that is fulfilling and satisfying.”
For Lustberg, it is important for physicians to recognize that the onus of creating work-life balance is not solely on themselves.
“I want to make sure we highlight system problems and prioritize these over what any one person can do,” she said. “For example, ensuring that very early meetings, late meetings and weekend emails are kept at a minimum can be low-hanging-fruit changes that can very quickly change organizational culture.”
Every organization that employs physicians must have an organizational well-being strategy that should include five components, Drummond said.
“These include education, social and cultural interactions outside of work hours, crisis management, stress reducing process improvement, and a world-class communication and awareness campaign so everybody knows what is being done to protect their health and happiness,” he said.
Having “meaningful connections” in the workplace is key, Charabaty said.
“Workplaces have to embrace a culture that values physicians’ autonomy and input regarding decisions that affect their practice, and provide comprehensive staff and administrative resources so that physicians can focus on what they do best and have trained for — providing high-quality care to patients,” she said.
The experts with whom Healio spoke cited several such resources, including adequate administrative time to catch up on EMR and clinical work — which prevents having to take work home — as well as staff and financial support to streamline day-to day-function, a flexible work schedule, adequate vacation and CME time, fair and comprehensive parental leave policies, a reasonable call schedule and effective support for professional growth within the workplace.
‘Rekindle’ a sense of community
Although no one person can influence some of the large systemic issues, it may be possible for individual providers to make an impact on the health systems in which they work.
Kerksieck and colleagues suggested that providers need to be proactive about defining their own boundaries.
“A big thing for physicians to do is have good communication with their team,” Katz said.
Just as health systems should be cognizant of scheduling meetings before or after certain times, providers should communicate their own meeting time boundaries.
“You can also let your team know that you should be called on your cell phone, rather than sent an electronic communication, if there is a patient emergency,” Katz said. “This allows you to turn off your email but keep your phone close in case of a situation that requires your immediate attention. Then you can focus on the administrative work or whatever else you need to do.”
Turning notifications off on the phone can help, as can setting personal boundaries for when to look at emails and other electronic communications, Katz said.
“This allows you to actually get work done and focus on patient care,” she said.
Apart from tech solutions, Katz emphasized exercise as a critical component of self-management, calling it a “huge” strategy to relieve stress and feel energized.
Exercise can go hand-in-hand with mindfulness, Lustberg said.
“Understanding and reminding yourself each day what values and goals are important to you can help,” Lustberg added. “I was sitting in clinic on a Friday evening and decided to leave a bit earlier so I could have the evening in my son. Did everything get cleared out in my in basket? No. However, I cleared out the urgent things and the rest I caught up on early the next week.”
Accepting that the job is sometimes difficult is another strategy Lustberg employs.
“Yes, I try to block my time better. Yes, I try to say ‘no’ more. But there are times when I cannot,” she said.
Burnout reduction efforts that focus on the individual — such as advising people to shut off emails or do yoga — can only go so far, Makaroun said.
“In reality, the problem is not with individuals but with the system, and the solutions to address burnout, therefore, have to be system changes,” she said. “It’s about much more than people managing stress better or peer support, even if that’s one part of it.”
The issue of “the growing disconnection between doctors” also must be addressed, Makaroun said.
“I would suggest trying to rekindle some sense of community among health care workers,” Makaroun said. “When we feel connected to one another, we can support each other and feel connected to the work.”
References:
Association of American Medical Colleges. Physician Specialty Data Report. Available at: https://www.aamc.org/data-reports/data/2022-physician-specialty-data-report-executive-summary. Accessed June 19, 2024.
Castles AV, et al. Open Heart. 2021;doi:10.1136/openhrt-2021-001678.
Kerksiek P, et al. Front Psychol. 2022;doi:10.3389/fpsyg.2022.892120.
Raffi J, et al. Int J Womens Dermatol. 2019;doi:10.1016/j.ijwd.2019.07.001.
Woodward R, et al. SAGE Open Med. 2022;doi:10.1177/20503121221085841.
For more information:
Aline Charabaty, MD, can be reached at acharab1@jhmi.edu.
Dike Drummond, MD, can be reached at dikedrum-mond@gmail.com.
Leah M. Katz, MD, can be reached at lk2563@cumc.columbia.edu.
Maryam Lustberg, MD, MPH, can be reached at maryam.lustberg@yale.edu.
Lena K. Makaroun, MD, MS, can be reached at kkm35@pitt.edu.
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